Surgical Treatment for Esophageal Cancer

Esophagectomy is the main treatment for esophageal cancer. The 2 histologic subtypes of esophageal cancer are squamous cell carcinoma and adenocarcinoma; these subtypes have different biologic features and treatment strategies. Although the prognosis of patients treated with surgery alone remains unsatisfactory, neoadjuvant therapy helps to improve outcome. A meta-analysis revealed that neoadjuvant chemoradiotherapy provides survival benefits for both histologic types, while neoadjuvant chemotherapy is useful for adenocarcinoma. In Western countries, neoadjuvant chemoradiotherapy is a standard treatment for resectable advanced esophageal cancer, while neoadjuvant chemotherapy has become the standard treatment in Japan. Esophagectomy can be performed by several different approaches, including McKeown (cervico-thoraco-abdominal), Ivor-Lewis (thoraco-abdominal), and transhiatal approaches. It has been suggested that Minimally Invasive Esophagectomy (MIE) contributes to the reduction of pulmonary complications. Cervico-thoraco-abdominal 3-field lymphadenectomy may prolong survival, but a randomized control study on this subject has not been conducted. Mortality and morbidity rates after esophagectomy remain high. Several meta-analyses demonstrated that esophagectomy at low-volume hospitals was associated with a significant increase in the incidence of in-hospital and 30-day mortality. The influence of hospital volume on long-term outcome continues to be a subject of debate. In conclusion, surgical resection remains the main treatment for potentially curable esophageal cancer. Neoadjuvant treatment can improve long-term outcome after esophagectomy. Furthermore, MIE may improve shortterm outcome, and 3-field lymph node dissection may reduce the risk of recurrence. The effects of these surgical procedures should be confirmed by randomized prospective studies.